20170224 Ver 1_Shoreline Stabilization_20170222

a
State of North Carolina
J Department of Environment and Natural Resources
Division of Water Resources
15A NCAC 02H .0500 — Water Quality Certification, Shoreline Stabilization
I�fJ� S foal 6� wk i e P-f,S "(W& FORM: SSGP 10-2013
Shoreline Stabilization Application Form 2 0 1 7 0 2 2 4
Three copies of the application (including attachments) and the application fee should be sent
to:
Division of Water Resources
401 & Buffer Permitting Unit
1617 Mail Service Center
Raleigh, NC 27699-1617
I. Applicant Information [ 15'A d6I+C 02 1.05162,],4
1. Owner Information
Name: t,
Mailing Address:
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16'5( r�3 (LI C t -"f l�li4 i C (2-51 B L VP iN M
Telephone Number: 72'l O I Go Fax Number: 17 7 6V3 -
E-mail Address: -Ae- w, It a V., s _ 630 a- ko cow
2. Agent/ Contact Person Information
A signed and dated copy of the Agent Authorization letter (a form can be downloaded here:
h+f-p b/1w w w, r: a w, 4.1.5 a c 2, oarw+y, � s�S9�do cs/rs�yu/o�orf� �%cs�P r r., ts�S/Nrl pC�S
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must be attached If the Agent has signed this application form.
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Name: Rof? l''%?iii/vf / %/ice 5;4:' CD .
Company Affiliation:
Mailing Address: 112, 0 -soy
�rC ,IVV-/ LGA /A1L- , Z�? 73 �
Telephone Number: °-4
�26 24V7 Fax Number: 6'ZP— 7,V 3 -6Z4 O
E-mail Address: „7 Q D 0.'e�©0 -5-C L a- o /' Co +I
Person to receive the C rtification Approval: 1967?/
11. Project Information [15-' 4 N(eAc 044, os oz (o) V 661
1. Attach a vicinity map (i.e. street map) clearly showing the location of the property with
respect to local landmarks such as towns, rivers, and roads.
2. Provide a detailed site plan showing property boundaries and proposed locations of
vegetation clearing, structures (buildings, retaining walls, docks, impervious surfaces,
FORM: SSGP 10-2013 Page 1 of 3

etc.), rip rap, excavation or dredging below Full Pond/ Normal Water Level elevations,
and construction access corridors. You may use the diagram provided at the end of this
application form.
3. Attach a photograph of the shoreline/ buffer proposed to be stabilized. (Include a scale
of some sort- a yard stick, shovel handle, etc.)
4. Location of the property (where work is to be conducted)
County: =// frj<_SwJ Nearest Town: C wxllk"c.-S l�
Subdivision name or site address (include phase/lot number):
/DSY ew Ale'
Directions to site - please include road names and numbers, landmarks, etc.:
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OGGOcy TO /0-57 G,CfT - L-,fAC�F_ �20NT
Latitude (in decimal degrees) 15Z6 L6 Longitude (decimal degrees) (P6 Z
5. Describe the existing land use or condition of the site at the time of this application
(residential, undeveloped, etc.): Tr U�-S�%fir
6. Property size (acres): If f -
7. Lake/ river/ ocean adjacent to property: GSA t//G6,.
8. Describe proposed work (include discussion as to how hardening of shoreline has been
avoided, or why it is necessary): 7-6 ,SVdAe6,Z1VJA6 ! IZV7 37?1U-_
57d. �ir� R+P 72-0-0
9. Will work be conducted from land? ❑ From water? [�
10. Total amount of disturbance (including all excavation, backfill, rip rap, retaining walls, etc.)
below the normal pool lake level/ Normal Water Level in square feet or acres:
/Z5
11. Total amount of disturbance (including all clearing, back fill, excavation, rip rap, retaining
walls, etc.) above the normal pool lake level/ Normal Water Level and 50 feet land -ward in
square feet or acres: %Z.- S6;
12. Please describe the vegetation above the normal pool lake level/ Normal Water Level and
50 feet landward to be impacted (number of trees, for instance): So m,!5-
/-/5=17
Owner/Agent's Signature [ Date
'Agent's signature is valid only if an authorization letter from the owner is provided.
FORM: SSGP 10-2013 Page 2 of 3

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